EM5408: Cranial Nerve

Examination

C. Robert Humphreys, MS, DC, DACNB, R. NCS.T.

EM5408 Head & Neck
• Go to Cygnet and download and READ the syllabus
• Download the Lecture and Laboratory Schedule
• Cygnet is the way the Instructor will contact you so you
should check for messages regularly.
• Your nuhs.edu email is the only way the Instructor has of
contacting you so please check this email regularly.
• Attendance will be posted every week on the Portal
 CN I: Olfactory
• Test ability to identify familiar aromatic odors, one naris
at a time with eyes closed.
• Have 2 or 3 vials of familiar aromatic odors available (film
canisters work well); substances should not contain alcohol or
mint, as both will cool the mucosa and can give false
responses.
• Black Tea
• Cinnamon
• Coffee
• Cloves
• Two issues in testing smell
• Does patient smell something?
• Entorhinal, parahippocamal, piriform & pariamygdala cortices
• Can they ID odorant?
• Olfactory Cortex (Orbitofrontal cortex, post. Inferior frontal lobe)
Abnormalities of Olfaction
1. Quantitative alteration of smell
a. Anosmia - Absence of the sense of smell
b. Hyposmia - Diminished olfactory sensitivity
2. Dysosmia
a. Qualitative Alteration or Distortion of the perception of smell
1. Parosmia
a) Distortion in the perception of an odorant. Smells different
than I remember
2. Phantosmia
a) Perception of an odor when there is no odorant present

3. Agnosia
a. Inability to classify, contrast, or identify odor sensations
verbally, even though the ability to distinguish between smells
may be normal
CN II: Optic
• Test Distant Visual Acuity with the Snellen chart
• Patient is 20 feet from Snellen chart
• Test each eye individually by covering one eye
• Record the smallest line in which the patient can identify all of the letters
• If the patient misses one letter in a line, report it as, i.e., 20/50 – 1,
• If the patinet misses two letters in the 20/50 line, report it as 20/70
• Have the patient read from right to left when testing the 2nd eye
• Test vision without glasses first
• Test Distant Near Acuity with the Rosenbaum Chart
• Chart is held at a distance of 14”
• Testing details are the same as with Snellen Chart.
 Visual Acuity

• Screening Tests
• Near Visual Acuity
Testing
• Rosenbaum card
@14”

Far Visual Acuity Testing

Snellen Chart @ 20’

Optic Nerve
• Diagnostic Delema:
• Eye problem
• Optic elements
• Cornea, tear film, lens, vitreous, retina
• Pathway lesion
• Lesion in the optic nerve – anopia
• Lesion in the lateral chiasm – nasal hemianopia
• Lesion in the medial chiasm – bitemporal hemianopia
• Lesion in the optic tract – contralateral homonomus hemianopia
• Lesion in the Loop of Meyer – contral superior homon hemianopia
• Lesion in the media pathway – contral inferior homon hemianopia
• Vision Review
• Evaluation of ocular function
3.Confrontational Visual Field Testing
b. Pathway Lesions
 Visual Field

Visual
Pathways

Optic nn

Optic Chiasm
Optic Tract

LGN
Optic radiation

Optic cortex
Cranial nerve II Visual field defects
• Left Anopia
– lesion L optic nn

– meningioma

– orbital tumor
 Cranial nerve II
Visual field defects
• Lt Nasal Hemianopia
-Lesion Lt lateral chiasm

– aneurysm internal carotid

Anatomic Relationships
Cranial nerve II
Visual field defects

Bitemporal hemianopia

– Lesion at chiasm affecting only

decussating fibers

-Pituitary tumors
 Cranial Nerve II
Visual field defects

• Lt Homomous Hemianopia

– lesion in R optic tract

– tumor
 Visual Pathways

Lateral Geniculate
Nucleus

Loop of Meyer
Cranial nerve II
Visual field defects

Right Superior homonomous quadrantanopia

-lesion L temporal lobe
Cranial nerve II
Visual field defects

Right Inferior homonomous quadrantanopia

-lesion L parietal lobe
Cranial nerve II
Visual field defects

Right Inferior homonomous quadrantanopia with

central sparing
-lesion L parietal lobe
Technique for examining strength of the extraocular muscles:

• Instruct the patient

• To follow your finger with their eyes and not their head
• To report if they see two objects at any time during the test
• Hold the pen 12-18” away from the patient’s face.
• Move slowly through an “H” pattern, noting any
weakness or nystagmus.
• Keep pen in same plane throughout test
Cardinal Fields of Gaze or H pattern of Gaze

IO
IO SR
SR

Nose MR
MR LR
LR

SO
SO IR
IR
Action of each extraocular muscle
“H” Pattern
“H” Pattern used
used for testing the
for testing the Left
Left Eye
Eye
CN III: Oculomotor (cont’d)
• Medial rectus, Superior rectus, Inferior rectus, Inferior
oblique, and levator palpebrae superioris muscles
• M.R. The eye moves medially (nasally) from the midline
position
• S.R. The eye moves superiorly from the extreme lateral
position
• I.R. The eye moves inferiorly from the extreme lateral position
• I.O. The eye moves superiorly from the extreme medial (nasal)
position
Observation?
CN IV: Trochlear
• Superior oblique muscle
• Testing the S.O.
• From the extreme medial (nasal) position, this muscle depresses the eye
CN VI: Abducens
• Lateral Rectus muscle
• L.R. The eye moves lateral from fixation position
Observation? Lesion location?

Bilateral LR weakness
Muscle Functions

Eye in
Eye in adduction
adduction Eye in
Eye in fixation
fixation Eye in
Eye in abduction
abduction

MR
MR -- add, -,-
add, -,- --

LR
LR -- abd, -,-, --
abd, --

SR
SR intort elev, int,
elev, int, add
add elevate
elevate

IR
IR extort
extort dep, ext,
dep, ext, add
add depress
depress

SO
SO depress
depress Dep, int,
Dep, int, abd
abd intort
intort

IO
IO elevate
elevate elev, ext,
elev, ext, abd
abd extort
extort

11oo,, 22oo,, 33oo actions

actions
CN III: Oculomotor (cont’d)
• Check pupils for size, accommodation, direct and consensual response to light
• Measure pupil size,
• Mytotic pupil <2 mm in diameter
• Increased parasympathetic or decreased sympathetic
• Mydriatic pupil > 6mm in diameter
• Decreased parasympathetic or increased sympathetic

• Test for ACCOMMODATION by having patient look at a distant object, then at a test object
(pencil/finger) held 4-6” from the bridge of the nose.
• Observe for convergence, constriction, and near visual acuity
• Test for Near Vision
• Observe for convergence, constriction,
Pupillary Responses
a. Abnormal pupillary responses can lead to decreased visual
acuity
b. Direct and consensual
c. Named for side the Dr. looks at
1) Look & shine light in same eye – direct
2) Look in one eye, shine in other eye – consensual

Left Right
Direct L II R II
L III R III
Consensual R II L II
L III R III
Pupillary light reflex
• Case:
• The right direct pupillary light reflex is not responsive.
The left direct and left consensual are responsive.
• What is the likely status of the right consensual
response?
• Where is the lesion?
 Left Right
1. Pupillary light reflex Direct L II R II
• The right direct pupillary light reflex L III R III
is not responsive. Consensual R II L II
L III R III

• The left direct and left consensual are Left Right

responsive. Direct L II R II
L III R III
Consensual R II L II
L III R III

• What is the likely status of the right Left Right

consensual response? Direct L II R II
• Where is the lesion? L III R III
Consensual R II L II
L III R III